[654] in libertarians
The Sex-Bias Myth in Medicine
daemon@ATHENA.MIT.EDU (Derek Rose)
Sun Feb 12 21:55:52 1995
Date: Sun, 12 Feb 1995 21:52:52 -0500
To: Dylan Carson <CAR0081057@acad.suffolk.edu>,
Joel Krieger <JOKRIEGER@delphi.com>,
John T Griffith <jogriffith@vaxsar.vassar.edu>,
Todd Seavey <Todd_Seavey@kaplan.com>, Chris Whitten <lfb@panix.com>,
libertarians@MIT.EDU, Ms Melissa L Preston <SEHA65B@prodigy.com>,
Anne Pollock <bubbah@leland.stanford.edu>,
Rufus Fowler <Rufowler@vaxsar.vassar.edu>,
Paul Gunn <pgunn@alkali.otago.ac.nz>,
Trent Adams <joadams@vaxsar.vassar.edu>,
Sean Lucey <lucey_s@jpmorgan.com>,
"David R. Throop" <throop@cs.utexas.edu>,
Dan Schorr <dschorr@sas.upenn.edu>,
Robert Gray <rgray@fas.harvard.edu>, HHSN43A@prodigy.com,
meteor@voyager.utc.uic.edu
From: Derek Rose <rosed@world.std.com>
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This is an article that appeared in the Atlantic Monthly magazine not too
long ago; I thought people might be interested. -Derek.
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Though it is commonly believed that American health-care delivery=
and
research benefit men at the expense of women, the truth appears to=
be
exactly the opposite
The Sex-Bias Myth In Medicine
by ANDREW G. KADAR, M.D.
The Atlantic Monthly, August 1994, pp. 66-70.
(c) 1994 The Atlantic Monthly Company.
Distributed under the "fair use" doctrine.
"WHEN it comes to health-care research and delivery, women can no=
longer be
treated as second-class citizens." So said the President of the United
States on October 18, 1993.
and the First Lady had just hosted a reception for the National=
Breast
Cancer Coalition, an advocacy group, after receiving a petition containing
2.6 million signatures which demanded increased funding for breast-cancer
prevention and treatment. While the Clintons met with leaders of=
the group
in the East Room of the White House, a thousand demonstrators rallied
across the street in support. The President echoed their call, decrying
the neglect of medical care for women.
Two years earlier Bernadine Healy, then the director of the National
Institutes of Health, charged that "women have all too often been=
treated
less than equally in . . . health care." More recently Representative=
Pat
Schroeder, a co-chair of the Congressional Caucus for Women's Issues,
sponsored legislation to "ensure that biomedical research does not=
once
again overlook women and their health." Newspaper articles expressed
similar sentiments.
The list of accusations is long and startling. Women's-health-care
advocates indict "sex-biased" doctors for stereotyping women as hysterical
hypochondriacs, for taking women's complaints less seriously than=
men's,
and for giving them less thorough diagnostic workups. A study conducted=
at
the University of California at San Diego in 1979 concluded that=
men's
complaints of back pain, chest pain, dizziness, fatigue, and headache=
more
often resulted in extensive workups than did similar complaints from=
women.
Hard scientific evidence therefore seemed to confirm women's anecdotal
reports.
Men more often than women undergo angiographies and
coronary-artery-bypass-graft operations. Even though heart disease=
is the
No. 1 killer of women as well as men, this sophisticated, state-of-the-art
technology, critics contend, is selectively denied to women.=20
The problem is said to be repeated in medical research: women, critics
argue, are routinely ignored in favor of men. When the NIH inventoried=
all
the research it had funded in 1987, the money spent on studying diseases
unique to women amounted to only 13.5 percent of the total research=
budget.
Perhaps the most emotionally charged disease for women is breast=
cancer.=20
If a tumor devastated men on a similar scale, critics say, we would=
declare
a state of national emergency and launch a no-cost-barred Apollo
Project-style program to cure it. In the words of Matilda Cuomo,=
the wife
of the governor of New York, "If we can send a woman to the moon,=
we can
surely find a cure for breast cancer." The neglect of breast cancer
research, we have been told, is both sexist and a national disgrace.=
=20
Nearly all heart-disease research is said to be conducted on men,=
with the
conclusions blindly generalized to women. In July of 1989 researchers=
from
the Harvard Medical School reported the results of a five-year study=
on the
effects of aspirin in preventing cardiovascular disease in 22,071=
male
physicians. Thousands of men were studied, but not one woman: women's
health, critics charge, was obviously not considered important enough=
to
explore similarly. Here, they say, we have definite, smoking-gun=
evidence
of the neglect of women in medical research--only one example of=
a
widespread, dangerous phenomenon.=20
Still another difference: pharmaceutical companies make a policy=
of giving
new drugs to men first, while women wait to benefit from the advances.=
And
even then the medicines are often inadequately tested on women.
To remedy all this neglect, we need to devote preferential attention=
and
funds, in the words of the Journal of the American Medical Women's=
Associati
on, to "the greatest resource this country will ever have, namely,=
the
health of its women." Discrimination on such a large scale cries=
out for
restitution--if the charges are true.=20
In fact one sex does appear to be favored in the amount of attention
devoted to its medical needs. In the United States it is estimated=
that
one sex spends twiceas much money on health care as the other does.=
The
NIH also spends twice as much money on research into the diseases=
specific
to one sex as it does on research into those specific to the other,=
and
only one sex has a section of the NIH devoted entirely to the study=
of
diseases afflicting it. That sex is not men, however. It is women.
In the United States women seek out and consequently receive more=
medical
care than men. This is true even if pregnancy-related care is excluded.=
=20
Department of Health and Human Services surveys show that women visit
doctors more often than men, are hospitalized more often, and undergo=
more
operations. Women are more likely than men to visit a doctor for=
a general
physical exam when they are feeling well, and complain of symptoms=
more
often. Thus two out of every three health-care dollars are spent=
by women.
Quantity, of course, does not guarantee quality. Do women receive
second-rate diagnostic workups?=20
The 1979 San Diego study, which concluded that men's complaints more=
often
led to extensive workups than did women's, used the charts of 104=
men and
women (fifty-two married couples) as data. This small-scale regional=
survey
prompted a more extensive national review of 46,868 office visits.=
The
results, reported in 1981, were quite different from those of the=
San Diego
study.=20
In this larger, more representative sample, the care received by=
men and
women was similar about two thirds of the time. When the care was
different, women overall received more diagnostic tests and treatment--more
lab tests, blood-pressure checks, drug prescriptions, and return
appointments.
Several other, small-scale studies have weighed in on both sides=
of this
issue. The San Diego researchers looked at another 200 men and women=
in
1984, and this time found "no significant differences in the extent=
and
content" of workups. Some women's-health-care advocates have chosen=
to
ignore data from the second San Diego study and the national survey=
while
touting the first study as evidence that doctors, to quote once again=
from
the Journal of the American Medical Women's Association, do "not=
take
complaints as seriously" when they come from women: "an example of=
a double
standard influencing diagnostic workups."=20
When prescribing care for heart disease, doctors consider such factors=
as
age, other medical problems, and the likelihood that the patient=
will
benefit from testing and surgery. Coronary-artery disease afflicts=
men at
a much younger age, killing them three times as often as women until=
age
sixty-five. Younger patients have fewer additional medical problems=
that
preclude aggressive, high-risk procedures. And smaller patients=
have
smaller coronary arteries, which become obstructed more often after
surgery. Whereas this is true for both sexes, obviously more women=
fit
into the smaller-patient category. When these differences are factored=
in,
sex divergence in cardiac care begins to fade away.
To the extent that divergence remains, women may be getting better
treatment. At least that was the conclusion of a University of North
Carolina/Duke University study that looked at the records of 5,795=
patients
treated from 1969 to 1984. The most symptomatic and severely diseased=
men
and women were equally likely to be referred for bypass surgery.=
Among the
patients with less-severe disease--the ones to whom surgery offers=
little
or no survival benefit over medical therapy--women were less likely=
to be
scheduled for bypass surgery. This seems proper in light of the=
greater
risk of surgical complications, owing to women's smaller coronary=
arteries.
In fact, the researchers questioned the wisdom of surgery in the=
less
symptomatic men and suggested that "the effect of gender on treatment
selection may have led to more appropriate treatment of women."
As for sophisticated, pioneering technology selectively designed=
for the
benefit of one sex, laparoscopic surgery was largely confined to=
gynecology
for more than twenty years. Using viewing and manipulating instruments
that can be inserted into the abdomen through keyhole-sized incisions,
doctors are able to diagnose and repair, sparing the patient a larger
incision and a longer, more painful recuperation. Laparoscopic tubal
sterilization, first performed in 1936, became common practice in=
the late
1960s. Over time the development of more-versatile instruments and=
of
fiber-optic video capability made possible the performance of more-complex
operations. The laparoscopic removal of ectopic pregnancy was reported=
in
1973. Finally, in 1987, the same technology was applied in gallbladder
surgery, and men began to enjoy its benefits too.
Years after ultrasound instruments were designed to look inside the=
uterus,
the same technology was adapted to search for tumors in the prostate.=
=20
Other pioneering developments conceived to improve the health care=
of women
include mammography, bone-density testing for osteoporosis, surgery
toalleviate bladder incontinence, hormone therapy to relieve the=
symptoms
of menopause, and a host of procedures, including in vitro fertilization,
developed to facilitate impregnation. Perhaps so many new developments
occur in women's health care because one branch of medicine and a=
group of
doctors, gynecologists, are explicitly concerned with the health=
of women.=20
No corresponding group of doctors is dedicated to the care of men.
So women receive more care than men, sometimes receive better care=
than
men, and benefit more than men do from some developing technologies.=
This
hardly looks like proof that women's health is viewed as secondary=
in
importance to men's health.
The 1987 NIH inventory did indeed find that only 13.5 percent of=
the NIH
research budget was devoted to studying diseases unique to women.=
But 80
percent of the budget went into research for the benefit of both=
sexes,
including basic research in fields such as genetics and immunology=
and also
research into diseases as lymphoma, arthritis, and sickle-cell anemia.=
=20
Both men and women suffer from these ailments, and both sexes serve=
as
study subjects. The remaining 6.5 percent of NIH research funds=
were
devoted to afflictions unique to men. Oddly, the women's 13.5 percent=
has
been cited as evidence of neglect. The much smaller men's share=
of the
budget is rarely mentioned in these references.
As for breast cancer, the second most lethal malignancy in females,
investigation in that field has long received more funding from the
National Cancer Institute than any other tumor research, though lung=
cancer
heads the list of fatal tumors for both sexes. The second most lethal
malignancy in males is also a sex-specific tumor: prostate cancer.=
Last
year approximately 46,000 women succumbed to breast cancer and 35,000=
men
to prostate cancer; the NCI spent $213.7 million on breast-cancer=
research
and $51.1 million on study of the prostate. Thus although about=
a third
more women died of breast cancer than men of prostate cancer, breast-cancer
research received more than four times the funding. More than three=
times
as much money per fatality was spent on the women's disease. Breast=
cancer
accounted for 8.8 percent of cancer fatalities in the United States=
and for
13 percent of the NCI research budget; the corresponding figures=
for
prostate cancer were 6.7 percent of fatalities and three percent=
of the
funding. The spending for breast-cancer research is projected to=
increase
by 23 percent this year, to $262.9 million; prostate-research spending=
will
increase by 7.6 percent, to $55 million.
The female cancers of the cervix and the uterus accounted for 10,100=
deaths
and $48.5 million in research last year, and ovarian cancer accounted=
for
13,300 deaths and $32.5 million in research. Thus the research funding=
for
all female-specific cancers is substantially larger per fatality=
than the
funding for prostate cancer.
Is this level of spending on women's health just a recent development,
needed to make up for years of prior neglect? The NCI is divided=
into
sections dealing with issues such as cancer biology and diagnosis,
prevention and control, etiology, and treatment. Until funding allocations
for sex-specific concerns became a political issue, in the mid-1980s,=
the
NCI did not track organ-specific spending data. The earliest information
now available was reconstructed retroactively to 1981. Nevertheless,=
these
early data provide a window on spending patters in the era before=
political
pressure began to intensify for more research on women. Each year=
from
1981 to 1985 funding for breast-cancer research exceeded funding=
for
prostate cancer by a ratio of roughly five to one. A rational,
nonpolitical explanation for this is that breast cancer attacks a=
larger
number of patients, at a younger age. In any event, the data fail=
to
support claims that women were neglected in that era.
Again, most medical research is conducted on diseases that afflict=
both
sexes. Women's health advocates charge that we collect data from=
studies
of men and then extrapolate to women. A look at the actual data=
reveals a
different reality.
The best-known and most ambitious study of cardiovascular health=
over time
began in the town of Framingham, Massachusetts, in 1948. Researchers
started with 2,336 men and 2,873 women aged thirty to sixty-two,=
and have
followed the survivors of this group with biennial physical exams=
and lab
tests for more than forty-five years. In this and many other observational
studies women have been well represented.
With respect to the aspirin study, the researchers at Harvard Medical
School did not focus exclusively on men. Both sexes were studied=
nearly
concurrently. The men's study was more rigorous, because it was
placebo-controlled (that is, some subjects were randomly assigned=
to
receive placebos instead of aspirin); the women's study was based=
on
responses to questionnaires sent to nurses and a review of medical=
records.
The women's study, however, followed nearly four times as many subjects=
as
the men's study (87,678 versus 22,071), and itfollowed its subjects=
for a
year longer (six versus five) than the men's study did. The results=
of the
men's study were reported in the *New England Journal of Medicine*=
in July
of 1989 and prompted charges of sexism in medical research. The
women's-study results were printed in the *Journal of the American=
Medical
Association* in July of 1991, and were generally ignored by the nonmedical
press.
Most studies on the prevention of "premature" (occurring in people=
under
age sixty-five) coronary-artery disease have, in fact, been conducted=
on
men. Since middle-aged women have a much lower incidence of this=
illness
than their male counterparts (they provide less than a third as many
cases), documenting the preventive effect of a given treatment in=
these
women is much more difficult. More experiments were conducted on=
men not
because women were considered less important but because women suffer=
less
from this disease. Older women do develop coronary disease (albeit=
at a
lower rate than older men), but the experiments were not performed=
on older
men either. At most the data suggest an emphasis on the prevention=
of
disease in younger people.
Incidentally, all clinical breast-cancer research currently funded=
by the
NCI is being conducted on women, even though 300 men a year die of=
this
tumor. Do studies on the prevention of breast cancer which specifically
exclude males signify a neglect of men's health? Or should a disease=
be
studied in the group most at risk? Obviously, the coronary-disease
research situation and the breast-cancer research situation are not
equivalent, but together they do serve to illustrate a point: diseases=
are
most often studied in the highest-risk group, regardless of sex.
What about all the new drug tests that exclude women? Don't they=
prove the
pharmaceutical industry's insensitivity to and disregard for females?
The Food and Drug Administration divides human testing of new medicines
into three stages. Phase 1 studies are done on a small number of
volunteers over a brief period of time, primarily to test safety.=
Phase 2
studies typically involve a few hundred patients and are designed=
to look
more closely at safety and effectiveness. Phase 3 tests precede=
approval
for commercial release and generally include several thousand patients.
In 1977 the FDA issued guidelines that specifically excluded women=
with
"childbearing potential" from phase 1 and early phase 2 studies;=
they were
to be included in late phase 2 and phase 3 trials in proportion to=
their
expected use ofthe medication. FDA surveys conducted in 1983 and=
1988
showed that the two sexes had been proportionally represented in=
clinical
trials by the time drugs were approved for release.
The 1977 guidelines codified a policy already informally in effect=
since
the world thalidomide tragedy shocked the world in 1962. The births=
of
armless or otherwise deformed babies in that era dramatically highlighted
the special risks incurred when fertile women ingest drugs. So the=
policy
of excluding such women from the early phases of drug testing arose=
out of
concern, not out of disregard, for them. The policy was changed=
last year,
as a consequence of political protest and recognition that early=
studies in
both sexes might better direct testing.
Throughout human history from antiquity until the beginning of this=
century
men, on average, lived slightly longer than women. By 1920 women's=
life
expectancy in the United States was one year greater than men's (54.6=
years
versus 53.6). After that the gap increased steadily, to 3.5 years=
in 1930,
4.4 years in 1940, 5.5 in 1950, 6.5 in 1960, and 7.7 in 1970. For=
the past
quarter of a century the gap has remained relatively steady: around=
seven
years. In 1990 the figure was seven years (78.8 versus 71.8).
Thus in the latter part of the twentieth century women live about=
10
percent longer than men. A significant part of the reason for this=
is
medical care.
In past centuries complications during childbirth were a major cause=
of
traumatic death in women. Medical advances have dramatically eliminated
most of this risk. Infections such as smallpox, cholera, and tuberculosis
killed large numbers of men and women at similar ages. The elimination=
of
infection as the dominant cause of death has boosted the prominence=
of
diseases that selectively afflict men earlier in life.
Age-adjusted mortality rates for men are higher for all of the twelve
leading causes of death, including heart disease, stroke, cancer,=
lung
disease, (emphysema and pneumonia), liver disease (cirrhosis), suicide,=
and
homicide. We have come to accept women's longer life span as natural,=
the
consequence of their greater biological fitness. Yet his greater=
fitness
never manifested itself in all the millennia of human history that=
preceded
the present era and its medical-care system--the same system that
women's-health advocates accuse ofneglecting the female sex.
To remedy the alleged neglect, an Office of Research on Women's Health=
was
established by the NIH in 1990. In 1991 the NIH launched its largest
epidemiological project ever, the Women's Health Initiative. Costing=
more
than $600 million, this fifteen-year project will study the effects=
of
estrogen therapy, diet, dietary supplements, and exercise on heart=
disease,
breast cancer, colon cancer, osteoporosis, and other diseases in=
160,000
postmenopausal women. The study is ambitious in scope and may well=
result
in many advances in the care of elder women.
What it will not do is close the "medical gender gap," the difference=
in
the quality of care given the two sexes. The reason is that the=
gap does
not favor men. As we have seen, women receive more medical care=
and
benefit more from medical research. The net result is the most important
gap of all: seven years, 10 percent of life.
# # #
Andrew G. Kadar, M.D. is an anesthesiologist and a member of the=
clinical
faculty at the UCLA School of Medicine.
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